Statement by the European Public Health Association (EUPHA) on migration, ethnicity and health
Migrants and ethnic minorities (MEM) often face serious inequities concerning both their state of health and their access to good quality health services. These inequities are increasingly being brought to light by public health researchers, but action to tackle them has lagged behind. To ensure that adequate attention is paid to the determinants of MEM health and the problems of service delivery that can confront these groups, health systems need to become more inclusive. The rising tide of populism and nationalism in European politics has created a hostile environment for such reforms.
Nevertheless, a new willingness to stand up for migrants’ rights is emerging at the level of international organisations. Member organisations such as the IOM, WHO, ILO and UNHCR have succeeded in placing migration centre stage at the United Nations, where ‘Global Compacts’ on migrants and refugees are currently being drafted.1 These are linked to the Sustainable Development Goals (SDGs) that define the UN’s development programme for 2015-2030.
The SDG’s, with their maxim of ‘leaving no-one behind’ and their emphasis on equity in all countries (not just ‘developing’ ones), provide welcome and explicit support for efforts to combat inequities in MEM health.
For those who are unwilling to see research on MEM health limited to a purely academic enterprise, these are encouraging moves. However, policies can only be as good as the data they are based on. EUPHA is therefore issuing this call to reduce the gap between researchers and policy-makers, in particular those responsible for setting research priorities and implementing findings. The statement addresses the following key issues, which are discussed in more detail in the Explanatory Memorandum:2 1.
The need for evidence-based policies on MEM health. How can the evidence base for policy reforms be strengthened? a. Fundamental concepts and data collection The need for more and better data should be the first priority in MEM health. Because of the failure of research funding bodies and health system managers to recognise the importance of a strong evidence base, researchers and service providers alike suffer from a shortage of crucial data.
Progress is also hampered by the lack of harmonisation of fundamental concepts.
b. MEMs’ state of health and its determinants Epidemiological evidence, based on population-based rather than clinical data, is badly lacking on many topics. On the principle “no smoke without fire”, it is often assumed that migrants’ main health problems are those on which most research has been carried out. However, priorities are often defined by myths rather than realities.
c. Issues concerning service delivery The interaction between health services and their MEM users, including issues of access, quality, utilization and communication, has become a major field of research within EUPHA.
Not enough attention is paid to the need to adapt health services to the needs of migrant and minority users. Quite independently of their particular vulnerabilities, MEMs have the right to affordable and effective health services of all kinds and at all times, not only in emergencies. Considerations of immigration policy should never be allowed to stand between them and the help they need.
2. The target group. Whereas most international organizations tend to confine their attention to migrants, the position of EUPHA has always been that ethnic minorities need to be considered as well. These include the descendants of migrants as well as indigenous minorities. Such groups may experience inequities at least as great as those affecting migrants, and often similar in nature. This has implications for data collection: both ethnicity and migrant status need to be taken into account.
3. The diversity of MEM groups. Over-generalising approaches that fail to acknowledge diversity within groups need to be replaced by ‘intersectional’ analyses that examine simultaneously the effects of socioeconomic position, sex/gender, age and many other variables, as well as their interactions. Instead of being targeted at monolithic categories such as ‘migrants’, ‘refugees’ or ‘minorities’, policies should focus on within-group differences and real need. A ‘grapeshot’ approach encourages stereotyping and inaccurate targeting. Neither migrants, refugees nor ethnic minorities should be labelled in their entirety as ‘vulnerable groups’: to do so is to stigmatise them and underestimate their strength and resilience. In service delivery, ‘diversity sensitivity’ is to be preferred to a narrow emphasis on ‘cultural competence’.
4. The need to return to a broader framing of migration. The influx of unauthorised entrants to the EU in 2015-2016 (the so-called ‘migrant crisis’) has led to a one-sided focus on the needs of forced and irregular migrants – ignoring the ‘routine’3 migration that is in no way a ‘crisis’. Moreover, whereas the response of policy-makers to the 2015-2016 influx focused mainly on asylum seekers and refugees, many of the newcomers have joined the EU’s existing population of migrants in irregular situations; this group is all too often neglected in both research and policy-making. 3 The word ‘routine’ is preferred to ‘regular’, in order to emphasize the fact that asylum seekers, despite often entering without authorisation, regularise themselves by making an asylum application. However, we do not wish to classify asylumseeking as ‘routine’. The distinction ‘forced/unforced’ is also avoided, because research has shown that it is impossible to regard these as mutually exclusive categories.
5. Combating the fragmentation of MEM health policy in Europe. Much duplication of effort and ‘reinventing the wheel’ results from insufficient coordination within and between responsible agencies. In addition to the intrinsic divisions between European countries and language communities, regional and international organisations often compete with each other instead of cooperating, which leads to wasted effort and lost opportunities to create synergies. Priorities should be based on the latest insights into public health and the position of MEM in today’s Europe.
6. More attention in EU research programmes for MEM health. MEM health was a central topic in the First and Second Programmes of the European Commission (EC), but apart from a sudden surge in financing for projects on asylum seekers and refugees, it has been seriously neglected so far in the Third Health Programme. EUPHA is concerned about the lack of attention in this programme for health inequities in general, and those affecting MEMs in particular.
7. Better provision of education and training on MEM health. Although this Statement is primarily concerned with the links between research and policy-making on MEM health, capacity building in both areas has to be supported by education and training directed at health workers of all kinds, researchers, managers and policy makers. This should not only be provided in optional additional courses, but as part of basic curricula.
Our network of national associations of public health represents around 20’000 public health professionals. Our mission is to facilitate and activate a strong voice of the public health network by enhancing visibility of the evidence and by strengthening the capacity of public health professionals. EUPHA contributes to the preservation and improvement of public health in the European region through capacity and knowledge building. We are committed to creating a more inclusive Europe, narrowing all health inequalities among Europeans, by facilitating, activating, and disseminating strong evidence-based voices from the public health community and by strengthening the capacity of public health professionals to achieve evidence-based change.